Individual
KELLY BUCKHOLDT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PH.D.
Contact information
Practice address
1500 E WOODROW WILSON AVE, JACKSON, MS 39216-5116
(601) 364-7903
Mailing address
1500 E WOODROW WILSON AVE, JACKSON, MS 39216-5116
(601) 364-7903
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
54955
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
07971063
—
MS
Enumeration date
04/30/2014
Last updated
04/26/2016
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